Plenty of countries actually still maintain some form of private insurance. It's just so heavily regulated and subsidized that it's defacto single-payer with private administration.

I'd have to dig deeper to be sure but it sounds like a hybrid of single payer (for catastrophic care) and consumer pay (for routine care) which makes it sound somewhat unique.

That's the exact model I have under a French system. Routine doctors visits (and prescriptions) are cash on the barrel head, with a reimbursement of 80% of reasonable and customary cost. If something happens that requires a trip to the hospital, that's directly billed. If I was completely indigent, I believe I'd be entitled to a special card that would bill my visits directly to the government.

Having said that, both inpatient and outpatient are private insurance (Genassur/Allianz). It also appears that they're going down the same road as the US. The insurance companies are selling first dollar coverage, and if I choose a provider in their network, they've worked out a deal with the doctor to bill the insurance company directly. I suspect that won't turn out well.

That those above the 400% poverty level get to pay for. If people are getting more coverage than they need or use, it sucks to be the people hit with higher premiums and taxes as a result.

Since you're so fond of the bootstraps approach to life, I'm sure you'd be fine with ending the regulatory cartel that limits access to and inflates the wages of those in the legal profession. Certainly you don't need such a handout.

Weep for the bros, if you like, those “lucky duckies” who earn too much to qualify for subsidies. Me? I can’t believe how many of those who are 19-25 live in poverty. All of those red column young adults on the left side earn less than 138% of the poverty line. All of them would qualify for the Medicaid expansion. Yet many of them, possibly most of them, won’t get it because of all the states who are refusing the expansion.

I think they are who health care reform was about. I think it’s pretty horrific that next year a large chunk of them will continue to be uninsured. But I guess the tragedy du jour will remain the “rate shock” for the bros.

If you want something to be upset about, think about the people in states with Republican governors who are going to reject Medicaid expansion (hi Rick Perry & Bobby Jindal) who end up in the hole between "normal" Medicaid coverage and adequate subsidy for purchasing insurance on the national exchange (because these states are also planning not to set up state exchanges). Instead of well-compensated lawyers whining that they can't get exactly the kind of coverage they want, we're talking about actually poor people who will be left with virtually no coverage at all.

In fact, it's even more pernicious than that. Those whining lawyers you write about, dotorg, are, as you say, "highly-educated". If they really need health insurance, there's a decent likelihood they could apply for and get a white collar job that came with health insurance. Sure, it might not be their dream job, it might not be as much money as working on contract, but it's still an option. An option those poor people in Rick Perry or Bobby Jindal's Medicaid hole are much less likely to have.

It will be interesting to see if there will be any backlash in those states. Red states tend to be poorer than average and receive more redistribution from the Federal government, even though there are a lot of poor white people who none-the-less vote Republican.

Or, conversely, what happens in the states that do adopt the changes when the federal funds taper off. I suspect we're going to be hearing a lot about the resulting education and other service cuts that are needed to make up for the growing healthcare burden.

I don't think everyone should be able to afford health insurance any more than I think everyone should be able to afford many other goods and services. Similarly, I do not think everyone should have to purchase insurance. Doing either requires that everyone have a certain amount of income, the use of which they have no discretion, regardless of their circumstances.

Our health "insurance" is far from being actual insurance. It seems we would benefit far more from reforming the costs and payment mechanisms than by simply requiring everyone buy into certain mandated plans (or have someone else buy in for them). I fully support pushing to lower healthcare costs, which improves access for everyone. I'd like to see health insurance move fully to an individual market and for a level of coverage to be available that requires patients to pay out of pocket for routine services (with other plans available for those who have a known level of routine care needed). As a result, I'm a big fan of the Atlas MD sort of arrangement.

As a prosperous society, I do think we have an obligation to provide a safety net for those who can't purchase their own healthcare or insurance. We shouldn't be turning people away in their hour of need. We should also demand that healthcare providers who want to enjoy preferential tax benefits provide true charity to their community, not the "minimum treatment, maximum gouging" that has become so common recently.

Not everyone should be insulated from the consequences of their conscious decisions. If you choose to not make provisions for your health, financial consequences may be the result. Bankruptcy certainly isn't pleasant, but it's far better than some of the consequences the insolvent have faced elsewhere and in different times.

I realize those of you here who would rather that everyone be protected and safe from their own decisions will rather disagree with me. I understand that. I personally would rather advocate for people to have the freedom to do what they need and for the public to be burdened with helping only those who cannot help themselves.

That those above the 400% poverty level get to pay for. If people are getting more coverage than they need or use, it sucks to be the people hit with higher premiums and taxes as a result.

In other words...

Quote:

‘Are there no prisons?”

‘Plenty of prisons,’ said the gentleman, laying down the pen again.’And the Union workhouses.’ demanded Scrooge. ‘Are they still in operation?’

‘Both very busy, sir.’

‘Oh. I was afraid, from what you said at first, that something had occurred to stop them in their useful course,’ said Scrooge. ‘I’m very glad to hear it.’

‘Under the impression that they scarcely furnish Christian cheer of mind or body to the multitude,’ returned the gentleman, ‘a few of us are endeavouring to raise a fund to buy the Poor some meat and drink, and means of warmth. We choose this time, because it is a time, of all others, when Want is keenly felt, and Abundance rejoices. What shall I put you down for?’

‘Nothing!’ Scrooge replied.

‘You wish to be anonymous?’

‘I wish to be left alone,’ said Scrooge. ‘Since you ask me what I wish, gentlemen, that is my answer. I don’t make merry myself at Christmas and I can’t afford to make idle people merry. I help to support the establishments I have mentioned-they cost enough; and those who are badly off must go there.’

‘Many can’t go there; and many would rather die.’

‘If they would rather die,’ said Scrooge, ‘they had better do it, and decrease the surplus population.”

Yes, Mr. Jim. Myself and others who make in excess of $45,960.00 per year are evil, scrooge-like people. How dare we question being required to shoulder the burdens of others or the effectiveness and efficiency of the programs we're forced to support?

No, that is the threshold you are no longer receiving a subsidy. Nor are you paying a surcharge, as MUCH wealthier people do.

We are a wealthy society. Some benefit of that should filter down to everyone in it, aside form bare subsistence. Aside from that, we already pay for emergency care for the uninsured anyway, at a cost that is more than the subsidies and standard if care that are being talked about here.

Or, conversely, what happens in the states that do adopt the changes when the federal funds taper off. I suspect we're going to be hearing a lot about the resulting education and other service cuts that are needed to make up for the growing healthcare burden.

You must be a lot of fun at parties:

"Sorry, I prefer an empty glass, since I can't stand the idea that a full glass might end up being a half glass at some point."

Yes, Mr. Jim. Myself and others who make in excess of $45,960.00 per year are evil, scrooge-like people. How dare we question being required to shoulder the burdens of others or the effectiveness and efficiency of the programs we're forced to support?

What % of government expenditure do you, in general, support?

I mean, I think the F-35 program's a bit of a boondoggle, but I still pay my taxes.

Or, conversely, what happens in the states that do adopt the changes when the federal funds taper off. I suspect we're going to be hearing a lot about the resulting education and other service cuts that are needed to make up for the growing healthcare burden.

You must be a lot of fun at parties:

"Sorry, I prefer an empty glass, since I can't stand the idea that a full glass might end up being a half glass at some point."

You don't know if people shouldn't have their lives ruined because they got appendicitis?

Had I not had insurance when I contracted appendicitis, the hospital costs would have exceeded my yearly, pre-tax income. I didn't do anything wrong, I just had a completely and totally unpreventable sudden incredibly dangerous illness. Should I have gone bankrupt as a result of that illness if I hadn't had or hadn't been able to afford insurance in the first place?

I don't weep only for males aged 20-30. I feel sorry for everyone who is about to feel the financial consequences of this law.

The kinds of policies mandated by the ACA go far beyond the type of coverage I think society needs to provide as a safety net.

I don't care about the name, but if we'd instead focused on providing true catastrophic coverage instead of also trying to cover routine services, you are right that I'd likely be far more in favor. It bothers me quite a bit, though, that exactly those types of policies were outlawed by the ACA. As I've said before, I had one; it was the right insurance for me at the time. Now, though, we're doing away with that option so that we can redistribute the expenses of high-cost, high-risk groups onto low-cost, low-risk groups.

Educational costs, including opportunity costs, are a red herring. English doctors have fewer years of education and it's free, but they are overtaken in net earning by their American counterparts within the first decade.

Not just less, a boatload less. Enough less over a career so that the amount spent of medical school becomes a rounding error. Hence red herring.

In any event we are only talking about 2-3 years of extra undergraduate work (Medical school starts right of of high school in much of the world.)

And there's no evidence the extra education gets thier patients anything. It seems to be a combination of an artificial barrier to entry erected to protect incumbents and a form of hazing. That sort of behavior should be punished not rewarded.

So English doctors are compensated less for spending less time and money on their education? I'm sorry. I don't see the problem here, and I don't see how that makes U.S. doctors leeches.

Obviously the issue is with the system, not the individual doctors. It's not like a person can decide for themselves to have less medical training--to get a license they're required to go through the current system. Licensing is good, but the current system takes far too long and costs far too much.

But as a group, the incumbent doctors certainly don't want to change things in a way that would lower their collective salaries. Unfortunately.

So English doctors are compensated less for spending less time and money on their education? I'm sorry. I don't see the problem here, and I don't see how that makes U.S. doctors leeches.

Obviously the issue is with the system, not the individual doctors. It's not like a person can decide for themselves to have less medical training--to get a license they're required to go through the current system. Licensing is good, but the current system takes far too long and costs far too much.

But as a group, the incumbent doctors certainly don't want to change things in a way that would lower their collective salaries. Unfortunately.

Well, that can and does happen to some extent, with people becoming PAs and NPs. As they become more common, their scope of practice is also likely to increase, as well. The change won't come from the doctors, it will come from the less deeply trained personnel undercutting them.

We should also demand that healthcare providers who want to enjoy preferential tax benefits provide true charity to their community, not the "minimum treatment, maximum gouging" that has become so common recently.

Not everyone should be insulated from the consequences of their conscious decisions. If you choose to not make provisions for your health, financial consequences may be the result. Bankruptcy certainly isn't pleasant, but it's far better than some of the consequences the insolvent have faced elsewhere and in different times.

Those are two mechanisms that provide care free of charge. If someone declares bankruptcy after getting medical services, the hospital is out of that money. Yet, the services provided were anything but free.

Who pays for charitable care and money that could not be collected due to defaults? Everyone who does pay their bills, either directly or through their insurance premiums. That is, in part, why hospital bills are unreasonably high.

Another part is that insurance companies negotiate lower rates and don't actually pay anything resembling the sticker price. I just got an eye exam and new glasses and, for paying cash, I got a 20% discount on the sticker price. I'm going to guess that insurance companies manage to negotiate at least as good a discount.

edit: to contribute something to the cost-cutting side, it seems to me that some deregulation would be appropriate. For example, in some states (including New York), you cannot request a blood test on your own. You need to go to a doctor's office and pay to have an MD place the order. You then go to the same testing center and get the same test done as you would if you ordered it on your own. The difference being that you get a call from the doctor's office vs. the full report otherwise. It'd be far more cost effective to get these tests done on your own and consult a doctor only if something's out of the ordinary. A reasonable insurance system should encourage people to take advantage of such saving opportunities.

Until a couple years ago, pharmacists in New York couldn't administer vaccines. Today, there's still regulation that bans the kind of discounts offered in other states for getting vaccines - which you'd think would be in the interest of public policy. In so far as vaccines are cost-effective, fewer people getting vaccinated is costly for a system, too.

Well, that can and does happen to some extent, with people becoming PAs and NPs. As they become more common, their scope of practice is also likely to increase, as well. The change won't come from the doctors, it will come from the less deeply trained personnel undercutting them.

That's sort of a distinction without a difference--if we redefine PAs and NPs such that they can perform all the duties of a doctor, it's the same as changing the requirements to be a doctor.

However we do it is fine with me, but the underlying point is that we need to do that second thing.

OK so it seems there is a trend of cash-only doctors popping up in the country. This provides for some direct competition to insurance-based doctors in providing lower cost services. This in general seems like a good thing, it lowers overhead costs for doctors, it reduces tons of red tape, and if it gains popularity, would force insurance companies to be more innovative or die.

Concierge medicine caters to a small group of hypochondriacs who need to call someone at 2am "Doctor, I have a red spot on my finger. Doctor, is this cancer? Doctor, am I going to DIE!!!!????". They are not necessarily rich but have enough money to pamper their hypochondria.

Any kind of serious illness results in huge expenses that only the very affluent will be able to pay out of pocket and this is where most expenses are generated.

The best analogy would be to bring up privately owned jetskis when discussing public transportation.

If you are sick/injured, you can't go to work so up to a point, it makes sense to make sure people are healthy or to fix them when they break.

It also makes sense that there be a strong market capable of paying for advanced medicine so that there is an incentive to make medical advancements without so much incentive that medical advancements are really just repacking (or re-patenting) inferior or sub-marginally superior products at a much higher price.

It's hard to price healthcare because rationally, a dying person ought to pay any amount to save their own life. Even below the extremes, its also hard to put a price on the ability to walk, talk, feed and wipe oneself or a price on how much pain relief is worth.

Yeah.. cash only practices are a blip. They make for sensational reading, but are a non-factor in the greater economy. They are touted to make the medical establishment and self-described rugged individualists feel better about their views.

If you are sick/injured, you can't go to work so up to a point, it makes sense to make sure people are healthy or to fix them when they break.

It also makes sense that there be a strong market capable of paying for advanced medicine so that there is an incentive to make medical advancements without so much incentive that medical advancements are really just repacking (or re-patenting) inferior or sub-marginally superior products at a much higher price.

I don't really see how this is responsive to the jobs program query. Which I think is a valid question, because when talking to someone trying to defend the medical-industrial complex, sooner or later something is trotted about about high paying jobs, with good growth prospects and something, something consumer driven economy.

But a little examination shows how terrible an argument it is. First, make-work should be a last resort only if there is no work around that actually has a decent multiplier (i.e. infrastructure spending). Second, even at that point, make-work jobs shouldn't be good, high-paying jobs. If they are, they will attract workers who could be doing something productive.